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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202916
Report Date: 05/02/2024
Date Signed: 05/02/2024 10:52:43 AM

Document Has Been Signed on 05/02/2024 10:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CROSSROADS AT 650 S BASCOM AVEFACILITY NUMBER:
435202916
ADMINISTRATOR/
DIRECTOR:		HARBIN, KAREEBFACILITY TYPE:
735
ADDRESS:650 S BASCOM AVETELEPHONE:
(669) 319-2140
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 28CENSUS: 18DATE:
05/02/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Jose RodriguezTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's post-licensing inspection. LPA met with Program Manager (PM), Jose Rodriguez.

Upon entrance, LPA signed in at the front desk. Posters were observed to include if you see something say something and personal rights. Facility license posted in a visible area. LPA toured the facility with PM to include 7 out of 12 bedrooms, common area, bathrooms, office spaces, storage closets, IT room, group room, staff break room, dining room, medication room, and kitchen. All exit routes were free and clear of obstruction. Sharp objects, medications, chemicals, and disinfectants observed in a locked space. All staff members present are fingerprint cleared and associated to the facility. Residents observed participating in activities.

Facility temperature maintained between 70 - 73 degrees Fahrenheit. Resident bedrooms observed with beds, linens, adequate lighting, desk, chair, and closet. Trash-can with lids observed in each bedroom. Women and Men's hot water temperature maintained between 105 - 108 degrees Fahrenheit. Facility has a sufficient supply of extra linens.
Facility refrigerators temperature maintained at 36 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. LPA observed at least 2 days worth of perishables and 7 days worth of non-perishables. Daily meal times posted throughout the facility.

LPA reviewed 4 resident files were maintained to include a medical assessment, TB result, appraisal/needs and services plan, safeguard of personal property and valuables, admission agreement, personal rights, and consent forms. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CROSSROADS AT 650 S BASCOM AVE
FACILITY NUMBER: 435202916
VISIT DATE: 05/02/2024
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 4 out of 4 residents centrally stored medications were reviewed. LPA observed 1 out of 4 resident's PRN medications were not written in the centrally stored medication record. PM was advised. Medication room observed with a completed first aid kit, sharps container, and emergency lighting. LPA reviewed 4 staff files were maintained to include fingerprint clearance, job application, health screening, TB result, and 1st aid certificate.

LPA observed the facility has a dual smoke alarm and carbon monoxide detector.

Documents were obtained to include the LIC500, resident roster, and resident intake documents to include the admission agreement.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Manager, Jose Rodriguez, Administrator, Kareeb Harbin, Licensing Regulations Manager, Lisa Giuliani and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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